An Indiana Tragedy Could Have Been Avoided with Operative IQ

An Indiana man died March 14, 2014, the day following a two-hour transport that was delayed nearly 45 minutes because the ambulance service allegedly ran out of oxygen.

After a respiratory issue surfaced 25 days after Richard Hall’s (70) open surgery, Prompt Ambulance Service was called to transport Hall the two hours from Mishawaka, indiana, to Loyola, a city outside of Chicago. Hall’s wife, Dona Hall, rode with her husband in the ambulance giving her a firsthand account of the event.

According to allegations from Dona Hall, while en route medics realized they did not have sufficient oxygen to sustain adequate patient care for the duration of the transport. The ambulance made it to LaPorte, Indiana where it reportedly took 45 minutes to receive the additional oxygen. The duration of Hall’s depleted oxygen level is unknown. However after the detour, the status of the call changed from transport to emergency. On arrival to Loyola Medical Center, doctors informed Dona Hall that her husband had been oxygen deprived and the probability of her husband becoming brain dead if he had another heart attack. They asked her if she wanted him brought back if such an event occurred. Hall filed a formal complaint with Indiana Emergency Medical Services Commission following her husband’s death.

Each state establishes regulations to ensure EMS services all abide by the same standards to keep patient care at acceptable levels. Indiana is no different. Indiana EMS is required to have about 4-6 hours of oxygen on a transport ambulance, according to regulations set by the Indiana EMS Commission. “None of the information we received show that anyone took the time to make sure that that ambulance had that on board”, said Hall family attorney, Peter J. Agostino. If Prompt Ambulance Service had utilized Operative IQ, they could have generated detailed reports to show when and by whom the inspection was completed, providing quick and confident verification to the family’s attorney.

The loss of a patient is an unfortunate part of the job for EMS providers. However, when a loss results from lack of oversight and preparation, it is simply inexcusable. “Oxygen, that’s just not something you should have to think about. Of course they’re going to have oxygen”, said Hall’s daughter, Dalona Daggy. Patients and their families put their trust in the knowledge and professionalism of EMS services during frightening and often extremely stressful times.

Hall’s family members hope that through this unfortunate incident, they can raise awareness of such avoidable mistakes. As an EMS provider, what can be learned from this mistake? Perhaps always completing a thorough inspection maybe the obvious first answer. However, simply stating that an action has been completed doesn’t always mean it’s been done. The Operative IQ system not only saves users time and money, but it creates a level of certainty that vehicles are ready to respond and establishes accountability to ensure inspections are completed to your service’s standards. An electronic check sheet with automatic par levels and current expiration dates greatly reduces the likelihood of incidences such as this. Don’t put patient’s lives at unnecessary risk. Know that every vehicle is prepared with required supplies while keeping crew members responsible for their inspections. Protect yourself and organization by reporting trends and uses.